Psychoeducation

Psychoeducation is a core feature of cognitive-behavioural therapy--and any good therapy. The term refers to information that a therapist provides a patient about the patient's symptoms or disorder, about the therapy model, and about how treatment will proceed, among other things. A lot of psychoeducation occurs in the first few therapy sessions, but psychoeducation also involves explaining new concepts and providing a rationale for in-session exercises or homework assignments over the entire course of therapy.

As a therapist, I sometimes forget the importance of psychoeducation. Particularly when I feel an urgency about helping a given patient, I make the mistake of cutting short the education part to try to jump ahead to a more "active" treatment phase. To avoid this error, I have to remind myself that good psychoeducation is part of the treatment: patients consistently demonstrate great interest in the information provided, express relief to learn that their symptoms are normal, and show greater commitment to therapy following psychoeducation. In fact, often when therapy doesn't seem to be having the intended effect, it's because I went too quickly and failed to psychoeducate sufficiently.

I had an experience today that reminded me just how powerful psychoeducation can be: I have a patient who suffers from obsessive compulsive disorder (OCD), an anxiety disorder characterized by intrusive thoughts and by repeated compulsive actions designed to eliminate the anxiety generated by the thoughts. During our session, we were discussing the nature of OCD and I emphasized the fact that intrusive thoughts* (e.g., I could jump in front of this bus; what if I had sex with my best friend's partner; my hands could be contaminated from that weird meat at lunch; I could drop the baby off the balcony) are normal and common, and that most almost everyone--OCD or not--experiences them. My patient was so happy and relieved to hear this that he kissed my cheeks when he left my office--not our usual way of saying goodbye!

My patient's reaction reminded me that psychoeducation is an important part of my job. Here are some examples of information that can make a big difference for patients:

• For patients with panic attacks: It's normal to think you're going crazy or to think you're having a heart attack during a panic attack. In fact, both are listed as panic symptoms in the DSM.
• For patients who feel guilty about being depressed: It's normal to feel guilty when you're depressed. In fact, guilt is one of the DSM criteria for diagnosing depression.
• For patients who fear their depression is making them stupid: Poor memory and difficulty concentrating are listed as DSM diagnostic criteria for depression.
• For patients with generalized anxiety: Worry and anxiety are maintained by intolerance of uncertainty.
• For depressed or anxious patients: Depression and anxiety can be maintained by beliefs about depression and anxiety (e.g., anxiety makes me productive; only stupid people are happy).
• For patients with insomnia: Many cases of insomnia can be cured through simple sleep hygiene (e.g., always going to bed at the same time; not eating, drinking, or exercising right before bed; eliminating noise and light in the bedroom).
• For mindfulness meditation clients: Meditating doesn't mean clearing your mind of all thoughts. Practicing mindfulness doesn't mean you'll be Zen all the time.
• And my favourite, for everyone: Thoughts aren't facts. Not everything you think is true. 

The examples listed above are everyday facts for cognitive-behavioural therapists, but gifts for patients. It's like when your dentist explains to you that exposed roots are common and are often caused by overzealous brushing; when your lawyer informs you that you need your neighbour's consent to build a fence on your shared property line; or when my athletic therapist told me that imbalances in muscle strength can produce knee pain. The gift is information that produces understanding and/or relief and/or a direction for moving forward (e.g., get a soft-bristled toothbrush; set up a meeting with your neighbour; stop exercising late at night; consider ways of increasing your tolerance for uncertainty). 

* NB: Everyone has intrusive thoughts, i.e., thoughts that seem to come out of nowhere and are inconsistent with our real feelings and values (e.g., we don't really want to jump in front of a bus or have sex with our best friend's partner). The difference is that someone who doesn't have OCD treats the intrusive cognition as an annoying but passing thought and lets it go, whereas someone with OCD perceives the thought as both realistic and dangerous, and needs to perform a compulsive behaviour to alleviate the anxiety generated by the thought.

Anecdote: Parallel Therapy Universe

In September, I explained how psychologists are just like other professional that you might consult--with a specific set of skills, knowledge, and training. Today I had an experience that demonstrated the remarkable similarities between two very different types of therapy:

Before work this morning, I had an appointment with an athletic therapist. I told her my problem: "One of my knees hurts when I run." After asking some questions to understand the background and history of the problem, she maneuvered my legs around, testing muscles and ligaments to determine a diagnosis. Then she educated me: "Sometimes when you have surgery on one knee, that leg never fully regains equal strength; over time, the discrepancy between the two legs forces the muscles and ligaments to compensate--pulling in weird directions and resulting in pain." Next, she guided me through a few exercises that will strengthen the weaker leg. Once she was sure I understood how to do them, she prescribed a few for homework and made sure I wrote them down. She took notes during our session and put them in my file.

After my athletic therapy appointment, I went to work and met with my first patient of the day, a socially anxious man in his late twenties. He told me his problem: "I have to give a toast at a friend's wedding this weekend and I'm so anxious about it I can barely breathe." After asking some questions to fully understand the situation, I asked him to write down some of the thoughts and feelings that come up when he imagines giving the toast. His thoughts included "I'll go blank and won't be able to give the toast," "The other guests will laugh at me," and "If that happens, I'll be humiliated and devastated." Then I educated him: "Often people who are anxious both overestimate the likelihood of a feared event and underestimate their ability to cope with it."

Next, I guided him through an exercise that involved rating the probability of each thought: Given his ample preparation and the notes he planned to bring to the wedding, he rated the probability of forgetting his toast at only 15%. Given that most of the guests were friends of his, he rated the probability that they would laugh at him at only 10%. Given that he had experienced embarrassment during public speaking in the past--but allowing that humiliation and devastation were probably exaggerated predictions--he rated the probability of humiliation and devastation if he forgot his toast at 60%. Together we did the math (15% x 10% x 60% = .009% chance of his feared outcome occurring) and explored the impact of calculating the probabilities on his anxiety. Once I was sure that my patient understood how to apply this strategy, I assigned the use of probabilities in other anxiety-provoking situations as homework for next week. I took notes during our session and put them in his file. 

There you have it! Regardless of type, it seems that therapy involves explaining the problem, testing and diagnosis, education, introduction of a new skill or exercise, practicing the skill/exercise, and homework.

The Apple of my Eye

Why do people love Apple products so much? Sure, many of us also love our best pair of jeans, our favourite book, or our sharpest chef's knife, but I think it's fair to say that we have beyond-reasonable affection for our MacBooks, iPhones, iPods, and iPads--and that we don't feel the same way about our coffeemakers, alarm clocks, or the PCs we have to use at work.

What's this outsized love about?

Among others, two features of Apple products elicit affection:

1) Anthropomorphism is the attribution of human characteristics or motivations to animals (e.g., My cat knows when I'm sad and comes to purr on my lap), to non-living objects such as cell phones (e.g., My phone thinks I want to say 'spring' when I'm trying to say 'sprint'), or to phenomena like the weather (e.g., This snowstorm is trying to make me miss my bus). Apple products are deliberately anthropomorphic: they have ultra-responsive touch screens, which makes us feel like we're communicating with them; they're silver or white with a sleep light that throbs like a gentle heartbeat (e.g., MacBook), rather than black and machine-like with flashing red or green lights.

2) Not only do they breathe and respond to touch, but many Apple products are tiny, captializing on the cute response. The cute response is an evolutionary concept that refers to a variety of features (small, smooth, rounded) that, across species, make something look cute. Now think of Apple products: like babies and unlike boxy old computers, Apple products, including most of their icons and features, are characterized by a general absence of sharp corners and right angles. Add miniatureness, and we're in love. I mean, who hasn't cooed over an iPod nano or iPad mini?

Why do we anthropomorphize? Anthropomorphism is hypothesized to help humans make sense of our environments and feel greater control. That is, assigning human motivations to our cats, dogs, laptops, and iPods makes it easier for us to understand and interact with them. Further, anthropomorphism has been demonstrated to be more common in people who are socially isolated, where it fills a need for connection. Think of Tom Hanks and Wilson the volleyball in Castaway.

Why do we like things that are tiny and cute? Evolution science suggests that mammals are hardwired to respond quickly and lovingly to anything with big eyes, a high forehead, a small nose, and an undersize chin. These cute features signal extreme youth, harmlessness, and vulnerability; they trigger our caring instincts, which is key for evolution since the infants of most mammal species are pathetically helpless and would quickly die without parental intervention.

Apple products capitalize on anthropomorphism and the cute response, at least partially explaining our boundless affection for inanimate gadgets. These features are no coincidence, but rather a careful design and marketing strategy.

NB: The flip side is that when we anthropomorphize, we make non-human entities responsible for their actions, explaining why we feel confused--if not humiliated and betrayed--when our gadgets don't work (e.g., "I charge it every day! I always keep it in its little case! I didn't do anything, but it's suddenly dead! How could my phone do this to me??").

Confirmation Bias

Confirmation bias refers to our tendency to seek and favour information that confirms our pre-existing ideas, and to interpret ambiguous information as supportive of our beliefs. That is, we pay attention to and believe information that confirms what we already think, while ignoring contradictory information. So for example, if I believe that the city where I live has the best restaurants in the world, I'll notice and remember every delicious meal I eat in my city--ignoring any poor customer service or bad food experiences, and forgetting about delicacies consumed in other cities.

How does confirmation bias manifest in clinical psychology practice?

We all have automatic thoughts and core beliefs about ourselves, others, and the world. Some of our problematic thoughts and beliefs aren't quite accurate and, reinforced by confirmation bias, they can be quite resistant to change. Consider one of my patients--an undergraduate student who was depressed after a longterm relationship ended. She was very lonely after the break-up, and frequently had the thought that everyone in the world but her was in a relationship. This recurring thought meant that every time she attended a social event, she was hyper-aware of couples and failed to notice people who had arrived alone or with friends. In our sessions, my patient repeatedly compared herself to her two best friends, both of whom were in relationships, ignoring that her sister and her roommate were both single.

As her depression deepened, my patient's recurrent thought was reinforced by confirmation bias and consolidated into a biased belief: if she was the only single person in her peer group, she must be unlovable. The belief that she was unlovable was in turn reinforced by confirmation bias: when her friends organized a huge surprise birthday celebration, she reported they were just looking for an excuse to party. When her lab partner asked her out, she assumed it was only because he wanted to copy her notes.  Her confirmation bias prevented her from taking in any information that contradicted her belief that she was unlovable, maintaining both the belief and the depression. 

You don't have to be clinically depressed to experience the effects of confirmation bias. Think about the last time you woke up in a bad mood. You probably paid a lot of attention to the guy whose massive backpack took up an extra seat on the subway, or to the fact that the elevator at work was out of service again. You probably failed to notice the gorgeous weather, or the delicious lunch your loving partner packed you. Why? Because these things didn't fit in with your preconceived idea that day that the world was a lousy place.  

How can we challenge confirmation bias?

The trick is to realize when we're in the grip of confirmation bias, to identify the bias, and to be willing to test it. Example: I have a patient who has a high-powered job and young kids, but her life is more difficult than it needs to be because she believes that fundamentally, other people are incompetent. Not only does this belief create interpersonal conflict, but it means that she can never delegate responsibility for any task or chore to her colleagues, her husband, or her kids because they're liable to do it wrong.

After a bit of psychoeducation about CBT, and some work on cognitive distortions, she agreed to test her belief. Armed with the scientific hypothesis "Others are incompetent," she set out to complete the following assignment: for one week, record evidence that supported or contradicted her belief. Evidence that supported the belief included "My husband put my daughter's diaper on backwards" and "The construction on my street that was supposed to be completed two months ago still isn't done." Contradictory evidence included "The tech support guy at work fixed my printer," "The airline actually served me the gluten-free meal I ordered," and "My son did his homework while I was away."

Faced with clear evidence that others are not always incompetent, my patient was forced to reconsider her belief. She modified "Others are incompetent" to "Other people can be incompetent sometimes, but often get it right." My patient's new faith in her husband, children, and colleagues smoothed relationships and allowed her to delegate tasks, leaving her a bit of time to relax.

Challenging confirmation bias is tricky and requires an open mind. If there's a thought or belief that's making you depressed or anxious ("I never do anything right"), creating relationship problems  ("No one could ever really love me"), or generating stress ("Asking for help implies weakness"), try looking around for information you might be ignoring, and for possible reinterpretations of the information you've been using to justify your belief! 

NB: Sneaky confirmation bias occurs on sites like Facebook that use algorithms to feed us information. Example: If in following the US election, you clicked on and "liked" all your Obama-supporting friends' statuses and ignored all your Romney-supporting friends' posts, your Facebook news feed narrowed, showing you more news from your Democrat friends and fewer posts from your Republican friends. Through the Obama supporters' posted statuses and articles, you learned more about why the Democrats were the better party, and received little information that challenged this perspective--maintaining and strengthening your bias.

Do Me a Favour

Mental health tip: Do your future self a favour.

In a prior post, I discussed how you can motivate yourself to keep your resolutions and to do things you don't feel like doing by connecting behaviour with values. Another way to motivate yourself to take care of annoying errands and tedious tasks is to view them as favours for your future self. For example, you might not feel like taking the clean sheets out of the dryer and making the bed right now, but when your tired future self retires to your bedroom at midnight, he or she will probably be pretty pleased that you did him or her that favour this afternoon. Another example: if you shlepped around shopping all afternoon, you probably don't really feel like making one more stop at the drugstore to buy shampoo. You might feel more motivated, though, when you consider the thanks you'll get from your tomorrow-morning self, who won't have to shampoo with body wash.

It can help to imagine the pleasure of your future self as he or she receives your favour, in the same way you might picture the face of a loved one opening a perfect gift. I used this trick today: It's Friday and I'm headed out of town for the weekend; my refrigerator is nearly empty, but I was strongly resistant to the idea of going out in the cold rain to get groceries. To motivate myself, I pictured the comfort and relief of my tired late-Sunday-night self, whom I know will be pleased to find provisions for Monday morning breakfast. Building on this kindness to my future self, I even convinced myself to wash all of the dishes before leaving (rather than leaving the skillet "to soak").

You can't always do favours for your future self, and different people will have different priorities. I have one friend who consistently practices what she calls Operation Integration: when she arrives home, she always puts her coat, keys, and bag where they belong, and unpacks any other items--rather than abandoning them in the entry way or only putting half her things away. She doesn't always feel like taking the time reintegrate her belongings, but her ten-minutes-later self is glad the apartment is tidy, and her next-morning self is glad she knows where to find her keys!

What favours do you do your future self?

NB: You can also do your future self a favour by not doing certain things. For example, you might be finishing a lovely meal out and really feel like having coffee with dessert--but it's 10pm. It could help to consider not having coffee as a favour to your midnight self, who would like a decent night's sleep.